Emory Healthcare Emory Healthcare Quality Credentialing Quality Credentialing

ProcessProcess

Dorothy Cook-Walter, JD – Director System Credentialing

& Medical Staff Services

October 13, 2006

Mission StatementMission Statement

To provide a system-wide, efficient and thorough centralized program to verify a practitioner’s credentials at the time of initial appointment and/or reappointment using standardized processes that ensure accuracy and meets or exceeds applicable State, JCAHO and/or NCQA accreditation standards.

So Many MastersSo Many Masters

Medicare COP (CMS)JCAHONCQAURACState Licensing BodiesManaged Care Plans

System CredentialingSystem Credentialing

The Emory Clinic Emory Children’s Center Emory Medical Care Foundation Emory Medical Affiliates Emory Specialty Associates Dialysis Access Center of Atlanta Emory University Hospital Emory Genetics Laboratory Emory Crawford Long Hospital Wesley Woods Geriatric Hospital Wesley Woods Long Term Care (Budd Terrace) Wesley Woods Long Term Hospital Emory Johns Creek Hospital (opening February 2007) Emory Ambulatory Surgery Centers 120 Managed Care Plans Select Specialty Hospital Medicaid CMO’s Traditional Medicaid, Medicare and Tricare

Getting StartedGetting StartedChair Request Form:

OFFICE OF SYSTEM CREDENTIALINGMEDICAL STAFF APPLICATION/CREDENTIALING REQUEST

The Department of ___________________________ requests an Emory Healthcare credentialing package be sent to the physician listed below. This physician will need privileges at the following facilities:

Emory Crawford Long Hospital Emory University Hospital Emory Children’s Center **Wesley Woods - Geriatric Hospital Emory Clinic **Wesley Woods - Long Term Hospital Emory Clinic Ambulatory **Wesley Woods - Long Term Care

Surgery Center (Budd Terrace) *Emory Medical Care Foundation ** Before requesting privileges at these facilities, *Physician must apply for staff privileges please verify the clinical services are available.

or be on staff at Grady Memorial Hospital. Emory Orthopedic Outpatient Surgery Center Emory Center for Pain Medicine (MOT) Emory Spine Physiatry Outpatient Surgery Ctr Grady Memorial Hospital

NAME:_______________________________________________ SS#: APPLICANT EMAIL TO SEND APPLICATION: ____________________________________ ADDRESS: ____ City: State: Zip: ___________APPLICANT TELEPHONE: __________________________________________________________________ESTIMATED START DATE: ________________________________________________PHYSICIAN’S BOARD CERTIFICATION SPECIALTIES: _____________ ______ PHYSICIAN’S PRACTICING SPECIALTY: ______________________________ Physician is currently on staff and requires additional privileges at the above-indicated affiliates.

Chair Signature: ______________________________________Department: _________________________________________Date: ______________________________________________

PLEASE FAX PROMPTLY TO EMORY HEALTHCARE SYSTEM CREDENTIALING: FAX: (404) 778-4819

WEBPAGES – GA MEDICAL LICENSE http://www.medicalboard.state.ga.us/index.html DEA http://www.deadiversion.usdoj.gov

MODERATE SEDATION EXAM http://ehcdevnotes1.eushc.org/modsedation.nsf NPI https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart

Processing ApplicationsProcessing Applications

1. Ensure applicants meet EHC credentialing requirements.

2. Verification of Information using Primary Sources or JCAHO/NCQA recognized third parties.

3. Documentation to support competency.

Credentialing Process

Applicant delivers completed applicationto System Credentialing…

Are all documents included?

Verification Process Completed.Licensure, Training, Education,

Experience, Competency Claims/Sanctions

Notify applicantto provide

missing documents

Interview completed, if applicableFile submitted to

Credentials Committee

Recommendation made To PSC for approval of applicantRecommendation made to

Interim Credentials & Policy Committee

(appointment effective monthly)

File routed to Medical Staff LiaisonsInterview letter sent to applicant (ECLH)

YES NO

It’s All About “Timing”It’s All About “Timing” Scenario # 1: New Hire

(initial appointment) starting July 1st

In order for physician to bill managed care plans on July 1st, their credentialing file must be submitted to the May Managed Care Credentialing Committee

Managed Care Plans load physicians within 45-50 days from receipt of the monthly mailing. Effective dates are usually the 1st of the month following the mailing.

All providers must have admitting privileges at a local hospital prior to the May Managed Care Credentialing Committee meeting.

Scenerio # 1 Cont’dScenerio # 1 Cont’dThe verification process on

average takes about 30 days and should occur during April and May

Based on Scenario #1, the chair request should be faxed to System Credentialing by March 1st.

The average number of days for the credentialing and enrollment process is around 120. If the application is not returned in a timely manner or is incomplete upon return, the process may take longer.

Just Some DataJust Some DataAugust 2005 thru July 2006August 2005 thru July 2006

Percentage of Emory Faculty Physicians enrolled in all managed care plans prior to hire date measured by plans effective dates = 76.63% (TEC- 83.8%)

Percentage of Emory Faculty Physicians that have completed the entire credentialing & enrollment process within 90 days - measured from the chair request date to latest plan effective date (excluding GA License/DEA)= 79.05% (TEC – 81.03%)

More Detailed Data More Detailed Data Billing Numbers Prior to Billing Numbers Prior to

Hire DateHire Date

ECC Data: 63.64%Low volumeApplications not returned within 30

daysLocal Hospital affiliation (CHOA Board only meets every other month)

EMCF Data: 68.52%Local Hospital Affiliation (Grady)Hired before enrollment completed

TEC Data: 83.80%Estimated hire date less than 90 to 120

days from receipt of chair request

Committee Domino’sCommittee Domino’sImportant Committee Important Committee

DatesDates EUH

Credentials/PSC - 4th Monday each month ECLH

Credentials 2nd - Monday each month PSC 4th - Tuesday each month

WWC Credentials - 1st Thursday each month PSC 2nd - Thursday each month

Emory Johns Creek - TBA Emory Healthcare Interium Credentials &

Policy Committee usually meets 4th Thursday and always one day before the Managed Care Credentials Committee each month.

Managed Care Credentialing Committee Meeting Usually held the last Friday of the month.

Just when you think Just when you think you're doneyou're done

Every two years all providers must be recredentialed because of state / federal / JCAHO requirements.

Applications are sent out to providers 180 days from the day of EHC Board approval date. (October 26, 2006 appointments all expire on October 26, 2008 unless reappointments occur prior to that date.)

Medicaid, Medicare and Medicaid, Medicare and Tricare EnrollmentTricare Enrollment

Applications are mailed to providers for completion

Once completed applications are received they are mailed to Medicare, Medicaid and Tricare

Provider numbers and effective dates are obtained about 8 weeks after a completed application has been received by the payor.

Medicaid, Medicare and Medicaid, Medicare and Tricare EnrollmentTricare Enrollment

Application Hold-upsGeorgia Medical LicenseDEA CertificateNPI LetterState Approval Letter

(PAs only) Primary MD Missing SignaturesAdditional Locations

(Medicaid)

Board Certification Board Certification ChallengesChallenges

Managed Care Plans require certification and recertification in the physician’s practicing specialtyBCBS—5 years from completion

of residencyRecertification upon expiration of

current board

Changes in Board Certification status reported to all plans

Physician Assistants Physician Assistants ChallengesChallenges

Composite State Board Process Primary Sponsor requests permission to

utilize PA first step Change in Primary Sponsor

- certified letter per rules & regulations Adding alternate supervising physician

requires Board approval Alternate supervising physician attach to

Primary NOT Physician Assistant If Primary leaves; PA must not work until

Composite Board approves another Primary

PA Challenges Cont’dPA Challenges Cont’d

EHC Credentialing Process (Medical Staff Bylaws Primary Sponsor requests permission from

EHC Board to utilize PA Application processed by System

Credentialing and

submitted to Chair/Chief for recommendation;

submitted to Credentials Committee for recommendation;

submitted to Professional Service Committee for recommendation;

submitted to EHC Board for approval. If Primary leaves, PA must not work until

EHC Board approves another Primary

Is Credentialing Is Credentialing Important?Important?

Poliner v. Presbyterian Hospital of Dallas ($366 million jury verdict - 2006)

Navarro – unlicensed healthcare worker who failed PA exam 4 times ($217 million jury verdict – October 2006)

Kadlec Medical Center v. Lakeview Anesthesia ($ 8.2 million jury verdict - 2005)

Rockefeller v. Kaiser Foundation Health Plan of Georgia (October 3, 2001) In the Court of Appeals of Georgia

Questions?Questions?